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From: Current Clinical Practice: Headache and Chronic Pain Syndromes:

The Case-Based Guide to Targeted Assessment and Treatment By: D. A. Marcus © Humana Press, Totowa, NJ

Pain in the Foot

CHAPTER HIGHLIGHTS

• Disabling foot pain affects about 10% of adults.

• Common causes of foot pain can be distinguished by pain location, response to walking, and physical examination findings.

• Plantar fasciitis is the most common cause of heel pain.

• Painful peripheral neuropathy affects about one-fifth of all patients with diabetes.

* * *

This morning, you have four new patients with diabetes with chief com- plaints of a pain in the foot. They are all here for an initial evaluation. Here are the stories each patient tells your nurse:

Patient 1: Ms. Harvey is a 55-year-old waitress. “I just live on my feet. I’ve always been a morning person, but now I dread getting up. The minute my foot hits the floor, I’m in agony!”

Patient 2: Mrs. Inwood is a 65-year-old art teacher. “I know this sounds crazy, but my feet feel like they’re freezing and on fire at the same time.

They even bother me when I’m just lying in bed at night. They’re so cold all the time; I wear thick socks even in the warm weather. When I get looks, I just tell people I’m an eccentric artist.”

Patient 3: Ms. Johnson is a 19-year-old college student. “I think I’ve become my grandmother! I’ve always been an athlete, running at least 5 miles each morning and evening. I really pushed myself this spring so I’d be in great shape this summer, and now I can’t even walk!”

Patient 4: Mrs. Klein is a 48-year-old secretary. “Every time I walk it hurts. The other day when I went to buy new shoes, the sale clerk suggested I switch to a “sensible” shoe. You should have seen the old lady shoes she tried to sell me!”

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1. EVALUATING FOOT PAIN

A survey of almost 5000 adults seeing general practitioners noted foot pain lasting at least 1 day during the preceding month in 20% of men and 24% of women (1). Current disabling foot pain was identified in 8% of men and 11%

of women. Only 36% of those reporting disabling foot pain had received medi- cal attention. The prevalence of foot pain increased with age, peaking between ages 55 and 64, when disabling foot pain affects 12% of men and 15% of women. Foot pain can significantly impair walking, as well as work, sports, and other leisure activities.

Although the chief complaints and brief histories in these four patients are typical, none has provided enough information to formulate an educated diagno- sis. While each patient has the same primary complaint, differences in history and examination can provide ready clues to diagnostic possibilities (Table 1).

Extracting important features to distinguish among common disorders depends on a targeted evaluation that focuses on high-yield questions and examination findings to help distinguish among the many possible causes of foot pain.

1.1. Developing a High-Yield Targeted Evaluation of Foot Pain

Evaluations of patients with foot pain should be targeted to specific likely clinical scenarios to help confirm or refute clinical diagnoses (Table 2). The same evaluation principles apply to each patient regarding features in the history, physical examination findings, and the need to proceed with testing. Details of the targeted examination are outlined in Table 3. The neurological examination in patients with foot pain should include vibratory testing to effectively identify peripheral neuropathy. Ideally, the slightest vibration perceived in the great toe of the examiner should also be detected in the healthy patient’s great toe. When

Table 1

Common Causes of Chronic Foot Pain Disease category Specific diseases

• Musculoskeletal B Plantar fasciitis

B Arthritis and joint disease

(e.g., rheumatoid arthritis, bunions, gout)

• Neuropathic B Peripheral neuropathy

B Compressive neuropathy (e.g., tarsal tunnel syndrome) B Neuroma

• Vascular B Peripheral vascular disease

• Dermatological B Corns B Calluses B Nail disorders

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testing elderly patients or patients with diabetes, peripheral neuropathy may be suspected when vibration that is perceived in the examiner’s great toe is no longer perceived at the patient’s lateral malleolus.

Unilateral Response Location versus bilateral to walking

• Morton’s B Ball of foot B Unilateral B Worse neuroma

• Peripheral B Distal foot B Bilateral B Usually better neuropathy or stocking

• Peripheral B Diffuse foot B Bilateral B Worse vascular disease

• Plantar B Heel B Usually B Worse with first step; better

fasciitis unilateral with prolonged walking

• Tarsal tunnel B Medial sole B Unilateral B Worse

syndrome and ankle

Table 3

Keys to a Targeted Evaluation of Foot Pain

• History B Clarify pain location—complete pain drawing.

B Identify pain descriptors—burning and numbness suggest neuropathic conditions.

B Note pain precipitants.

B Record pain provokers and pain response to walking.

B Identify additional medical conditions, such as diabetes, rheumatological disorders, and malignancies that suggest systemic cause of pain.

B Obtain complete review of systems.

• Physical examination B Vascular evaluation

 Include temperature and color B Musculoskeletal exam

 Identification of joint deformities or cutaneous abnormalities (e.g., corns, warts, calluses), ROM, palpation of bones and tendinous insertions.

B Neurological exam

 Gait examination and strength and sensory testing, including vibration.

• Testing B Imaging studies, including X-ray and MRI when history suggests trauma, fracture, infection, or mass lesions.

B NCS/EMG for peripheral or compressive neuropathy.

B Doppler ankle/brachial pressure index for vasculopathy.

MRI, magnetic resonance imaging; NCS/EMG, nerve conduction studies/electromyography;

ROM, range of motion.

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1.2. Applying the Targeted Exam to Each Patient

Pain drawings for each patient revealed only pain in the foot or feet. In patients with pain in the feet only, a supplemental pain drawing (Fig. 1) may be used to better clarify the location and quality of the foot pain. Pain location is characteristic for several common chronic foot pain conditions (Fig. 2). The results of the targeted evaluation for each patient are provided in Tables 4 to7.

Read each patient’s findings, decide if additional testing is necessary, and for- mulate a likely diagnosis. Then read the following sections to compare your interpretations with the patients’ diagnoses in the clinic.

Fig. 2. Location of common unilateral foot pain syndromes. M, Morton’s neuroma;

P, plantar fasciitis; T, tarsal tunnel syndrome. (Reprinted with permission from ref.

1a.)

Fig. 1. Pain drawing for patients with foot pain. Patients are instructed to place an

“X” at the area of maximum pain. Also, they should shade all painful areas using the following key: //// = pain; :::::: = numbness; **** = burning or hypersensitivity.

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1.2.1. Patient 1: Ms. Harvey—55-Year-Old Waitress (Table 4)

Ms. Harvey’s pain involves her left heel, with severe tenderness to palpation over the anterior aspect of her calcaneus. Her pain is also reproduced by dorsiflexing the foot (Fig. 3); other movements of the ankle and foot do not cause pain. Foot inspection, vascular, and neurological examinations are unre- markable, except for a mild, chronic foot drop. No additional testing is ordered.

Ms. Harvey’s report of severe, nontraumatic heel pain, with maximal pain experienced on the first steps in the morning is typical of plantar fasciitis, a common cause of foot pain and the most common cause of severe heel pain.

Patients with plantar fasciitis typically report their pain is at its worst when they first try to get out of bed in the morning and is aggravated after pro- longed sitting. The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for 1995 to 2000 identified more than 1 million patient visits annually in the United States for plantar fasciitis (2). Plantar fasciitis is experienced as an excruciating heel pain that increases when the foot is kept in a plantar flexed position, as occurs during sleep.

When the foot is first dorsiflexed, such as when getting up out of bed in the morning, the pain is unbearable. Once the area has been stretched, as occurs with repeated foot dorsiflexion or with prolonged walking, the pain lessens.

Ms. Harvey—55-Year-Old Waitress Targeted assessment Findings

History B Pain is in her left heel.

B Pain is severe and sharp, “like a knife cutting through my foot. I’m sure my heel bone’s broken.”

B Pain began without any trauma and is slowly getting more severe.

B Pain is most severe when she first gets out of bed, then lessens by the time she has dressed and walks downstairs for breakfast. It comes back every time she is off her feet for a break during the day.

B ROS: type 2 diabetes managed with oral hypoglycemic, obesity, mild hypercholesterolemia, and mild foot drop after hysterectomy 1 year ago.

Physical exam

• Vascular B Good color and temperature; normal pulses.

• Musculoskeletal B No obvious joint deformities or cutaneous abnormalities.

Left foot dorsiflexion reproduces pain. Dorsiflexion of right foot is restricted with no pain report. Severe tender- ness when palpating left medial calcaneal tubercle.

• Neurological B Normal neurological examination, except for minimally decreased left foot dorsiflexion.

ROM, range of motion; ROS, review of systems.

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Every time the foot rests, such as with sitting or going to bed, the area tight- ens, and severe pain is experienced again with the first step. A matched, case- controlled study identified obesity, spending most of the workday on one’s feet, and reduced ankle dorsiflexion of both the affected and even the unaf- fected foot as independent risk factors for plantar fasciitis (3). Plantar fasciitis is common in runners, dancers, and individuals with foot pronation. Ms.

Harvey experienced a compressive peroneal neuropathy during her hysterec- tomy 1 year ago, with a resultant mild foot drop. Foot drop results in both reduced foot dorsiflexion and excessive pronation, both of which increase the risk for developing plantar fasciitis.

As with Ms. Harvey, radiographic studies in patients with plantar fasciitis symptoms are generally reserved for patients who fail to respond to conserva- tive therapy. About half of those with plantar fasciitis will have heel spurs on X-ray, although these are generally unrelated to their pain symptoms. Mag- netic resonance imaging (MRI) scans in plantar fasciitis typically show edema and thickening of the plantar fascia. In severe cases, tears may also be detected with MRI.

1.2.2. Patient 2: Mrs. Inwood—65-Year-Old Art Teacher (Table 5)

Mrs. Inwood describes bilateral, diffuse foot pain associated with allodynia (the perception of increased pain with sensations). Although she reports “cold- ness” in her feet, her pulse, coloration, and skin temperature suggest good vas- cularization. No musculoskeletal abnormalities are identified. No additional testing is ordered.

Fig. 3. Foot flexion. Dorsiflexion occurs with bending the foot up or heel walking.

Plantar flexion occurs with bending the foot down or walking on the toes.

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Mrs. Inwood is diagnosed with peripheral neuropathy, which is typically described as a burning pain that is aggravated by sensory stimulation, such as light touch, cold, or vibration. Like many patients with peripheral neuropathy, Mrs. Inwood does not describe her feet as numb or lacking sensation, but reports allodynia. In patients with peripheral neuropathy, allodynia frequently results in complaints of intense foot pain with changes in temperature or light touch, such as bedclothes brushing against the feet. Patients will also often report an unnatural cold perception to the foot or a feeling that the feet are “dead.” Walk- ing may either improve or aggravate neuropathic pain, although pain is usually better with walking and worse when lying in bed. Unlike a mononeuropathy or compressive neuropathy, which is usually unilateral, most cases of peripheral neuropathy produce bilateral symptoms. Early symptoms occur distally. As neuropathy progresses, patients will develop the characteristic “stocking”-area pain and sensory loss.

Mrs. Inwood—65-Year-Old Teacher Targeted assessment Findings

History B Pain affects both feet diffusely below the ankles.

B Pain is burning and tingling.

B Pain has slowly developed over the last year. No preced- ing trauma.

B Worst pain occurs at night when lying in bed.

B Pain usually is less noticeable when she is walking, although it comes right back once she stops walking.

B ROS: type 2 diabetes, well controlled until 1 year ago when she divorced and switched jobs. “I’ve been under too much stress and depressed to watch my diet and medicine. Things should get back to normal soon.”

Treated with tricyclic antidepressants after her divorce, which caused excessive sedation. Otherwise, controlled hypertension.

Physical exam

• Vascular B Good color and temperature; normal pulses

• Musculoskeletal B No obvious joint deformities or cutaneous abnormalities.

Full ROM of foot and ankle. Firm palpation not more bothersome than light touch.

• Neurological B Normal gait and strength testing. Absent ankle reflexes bilaterally. No numbness, but reports light touch and pin prick are very bothersome diffusely in both feet. Vibration felt at examiner’s toe is not perceived at the patient’s great toe or ankle. Vibration is only felt when the tuning fork is so strong that an audible sound can be heard.

ROM, range of motion; ROS, review of systems.

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Peripheral neuropathy occurs in a variety of medical illnesses, including endocrine, rheumatological, liver, kidney, infectious, malignant, and nutri- tional disorders. A survey of patients seeing primary care doctors identified chronic painful peripheral neuropathy in the lower extremity in 5% of nondiabetics and 17% of patients with diabetes (4). Interestingly, patients with diabetes with and without peripheral neuropathy shared similar diabetes type and duration of illness, glycemic control, and vascular risk factors. Also of note, 39% of the patients with diabetes with neuropathy had never received treatment for neuropathic pain, including 12% who had not consulted for their pain. A large, prospective, longitudinal survey evaluated more than 3000 pa- tients with type 1 diabetes (average age = 33 years) with an initial assessment and follow-up after 6 to 10 years (5). At baseline, 29% of patients had neur- opathy. Of those without neuropathy at the initial assessment, neuropathy de- veloped by the time of the follow-up (average time = 7 years) in 24%. In these patients, longer duration of type 1 diabetes, poor blood sugar control, cardio- vascular risk factors, and smoking were all independent predictors for devel- oping neuropathy at follow-up. Obesity has also been linked to increased risk for neuropathy in patients with type 1 diabetes (6). Another large survey iden- tified peripheral neuropathy in 60% of 866 patients with type 2 diabetes (aver- age age = 57 years) attending a diabetic clinic. This survey similarly linked longer duration of type 2 diabetes and poor blood sugar control to increased risk for neuropathy (7).

The diagnosis of peripheral neuropathy may be confirmed using nerve con- duction studies. Nerve testing is typically reserved for patients when there is no apparent cause for peripheral neuropathy, the diagnosis cannot be clearly confirmed on clinical examination, or compressive neuropathies or other neu- rological conditions are considered in the differential diagnosis.

1.2.3. Patient 3: Ms. Johnson—19-Year-Old Student (Table 6)

Ms. Johnson’s foot pain began after overuse, with an aggressive workout schedule before her long summer backpacking trip. She describes a neuropathic pain over her ankle and arch, with no mechanical or vascular abnormalities. No additional testing was ordered.

Ms. Johnson’s history and examination are characteristic of a compressive neuropathy of the posterior tibial nerve known as tarsal tunnel syndrome. As seen in Ms. Johnson, this pain may be reproduced by percussing the posterior tibial nerve behind the medial malleolus or by dorsiflexing and everting the foot. In tarsal tunnel syndrome, nerve entrapment occurs in the tunnel formed behind the medial malleolus by the flexor retinaculum (a fibrous band located between the medial malleolus and the calcaneus) (Fig. 4). Tarsal tunnel syn- drome causes a vague pain and numbness over the medial ankle, heel, sole, and foot arch. This pain is caused by compression of the tibial nerve as it passes

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behind the medial malleolus posterior to the tibial artery. Unlike plantar fasciitis, which improves with prolonged walking, tarsal tunnel pain is aggra- vated by walking. In addition, percussing the flexor retinaculum may result in an electric shock-like pain, similar to percussion at the wrist for carpal tunnel syndrome.

Ms. Johnson—19-Year-Old Student Targeted assessment Findings

History B Pain affects her right ankle, heel, and arch. Her drawing shows symbols for pain, numbness, and burning over this entire area.

B Pain began during the last 3 days of a 2-month-long sum- mer backpacking trip along the Appalachian trail. There was no specific injury that occurred on this trip.

B “Bumping the bone inside my right ankle puts me through the roof!” Walking also aggravates her pain, which gets worse the longer she walks.

B ROS: type 1 diabetes, well controlled.

Physical exam

• Vascular B Good color, temperature, and pulses in both feet

• Musculoskeletal B No obvious joint deformities or cutaneous abnormalities.

B Full ROM of foot and ankle. Pain was reproduced when the examiner pushed the toes and foot up and laterally.

Area of point tenderness behind tibial artery. Percussion here reproduces pain.

• Neurological B Normal neurological examination.

ROM, range of motion; ROS, review of systems.

Fig. 4. Anatomy of the posterior tibial nerve. The posterior tibial nerve travels into the foot under the flexor retinaculum.

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Tarsal tunnel syndrome may be caused by mechanical dysfunction (includ- ing trauma), mass lesions (including varicosities, cysts, osteophytes, and tu- mors), and metabolic disorders causing swelling (including rheumatoid arthritis, diabetes, and thyroid disease) (8). Tarsal tunnel syndrome has been reported in runners (especially after excessive training), with prolonged hik- ing, and after wearing compressive skates and ski boots (9–12). A recent sur- vey of long-distance backpackers identified foot numbness or paresthesias in 34% of patients (10). Although most cases were considered nonspecific paresthesias, tarsal tunnel syndrome was diagnosed in 6% of those with foot symptoms. Paresthesias occurred more frequently in backpackers who were female, younger, and those hiking more than 2000 miles. In 98% of backpack- ers, symptoms resolved before follow-up, which occurred after an average of 1 month. Both ankle stress and hiking boot compression may contribute to the development of tarsal tunnel syndrome in hikers.

1.2.4. Patient 4: Mrs. Klein—48-Year-Old Secretary (Table 7)

Mrs. Klein’s pain is located discretely in the ball of her left foot, with an electrical pain produced consistently with pressure over this area, as reported in the history and noted during the physical examination. There are no neuro- logical, mechanical, or vascular deficits. No additional testing was ordered.

Point tenderness over the ball of the foot in Mrs. Klein is consistent with the diagnosis of Morton’s neuroma. Morton’s neuroma typically affects the third common digital nerve, resulting in a pain in the ball of the foot that occurs with each weight-bearing step. Walking may also cause a tingling or electric shock-

Table 7

Results of Targeted Evaluation for Patient 4:

Mrs. Klein—48-Year-Old Targeted assessment Findings

History B Pain is located in the ball of the left foot. “It feels like I’m walking on a marble.”

B Pain began without trauma.

B “Every step gives me a jolt of pain. The more I walk, the worse I feel.”

B ROS: type 2 diabetes, controlled with diet and exercise.

Physical exam

• Vascular B Good color, temperature, and pulses in both feet.

• Musculoskeletal B No obvious joint deformities or cutaneous abnormalities.

B Full ROM of foot and ankle. Palpation of the ball of the foot around the third metatarsal reproduces pain.

• Neurological B Normal neurological examination.

ROM, range of motion; ROS, review of systems.

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like pain around the second to fourth metatarsals. Women are more commonly affected than men. This pain will be aggravated by wearing pointed-toe, high- heel shoes. The neuroma can usually be isolated by squeezing the sides of the feet together with one hand, while pressing the ball of the foot with the other thumb. This should reproduce the pain of Morton’s neuroma. Larger Morton’s neuromas will usually be visible on MRI scans and ultrasound, although imag- ing studies are generally not necessary.

2. TREATING FOOT PAIN

Disease-specific restorative treatments may be used to treat recalcitrant tar- sal tunnel syndrome and Morton’s neuroma. Treating plantar fasciitis in Ms.

Harvey and peripheral neuropathy in Mrs. Inwood will necessitate long-term chronic pain management. The initial treatment of tarsal tunnel syndrome and Morton’s neuroma is also conservative.

2.1. Plantar Fasciitis

Although early suspicion of inflammation as the cause of plantar fasciitis led to the development of its current name, plantar fasciitis is primarily a non- inflammatory condition, caused by stress and degenerative changes in the plan- tar fascia and degenerative reduction in the heel pad. Treatment, therefore, focuses on stretching a shortened and stiff plantar fascia, providing arch and heel support to reduce foot pronation, and provide protective cushioning of the heel (Table 8).

A prospective study randomized 236 patients with plantar fasciitis to stretch- ing exercises alone or stretching plus orthotics (13). After 8 weeks of treat- ment, the outcome was superior in patients treated with prefabricated orthotics

Nonmedication Medication

• Restorative B Stretching exercises with frequent foot dorsiflexion B NSAIDs treatment B Supportive shoes with good medial arch support

B Orthotics to reduce foot pronation and cushion the heel

• Preventive B Stretching exercises B None

therapies B Supportive footwear; consider 90q night splints

• Flare B Ice B NSAIDs

techniques B Stretching exercises B Analgesics

B Relaxation techniques NSAIDs, nonsteroidal anti-inflammatory drugs.

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plus stretching compared with stretching alone for both pain reduction (38%

versus 29%) and percentage of patients improving with treatment (88% versus 72%).

Ms. Harvey was provided with an educational flyer on plantar fasciitis (Box 1) and advised to wear supportive footwear at all times. She was also given a heel lift wedge to elevate her medial foot slightly to prevent prona- tion, and was advised to consider shoe inserts to also maintain proper foot posture. She was instructed to perform stretching exercises of her Achilles tendon and plantar fascia in the morning and evening. In addition, she was instructed to avoid resting with her foot plantar-flexed, as well as advised to regularly dorsiflex her foot during the day when she was sitting and for 5 minutes in the morning before getting out of bed. After 2 weeks, her morning pain was significantly reduced. She noticed that, for the next 6 months, she needed to perform her stretching regularly to prevent the return of pain.

2.2. Peripheral Neuropathy

Peripheral neuropathy related to systemic disease may be improved by treat- ing the primary systemic illness (Table 9). A longitudinal study comparing patients with diabetes treated with aggressive glucose management versus con- ventional therapy showed a reduction in the development of neuropathy of 60% during 5 years in patients treated with aggressive glucose regulation (14).

In addition, good blood sugar control retards the progression of peripheral neu- ropathy (15).

Both antidepressants and anti-epileptic drugs can effectively reduce the dis- comfort of peripheral neuropathy. Tricyclic and dual-action antidepressants are more effective than selective serotonin reuptake inhibitors (16). Gabapentin (Neurontin®) and pregabalin (Lyrica®) also effectively reduce neuropathic pain and are better tolerated than other anti-epileptics (17).

Table 9

Targeted Treatment of Peripheral Neuropathy

Nonmedication Medication

• Restorative B Management of underlying medical B Management of under-

treatment condition lying medical condition

• Preventive B Management of underlying medical B Antidepressants

therapies condition B Anti-epileptics

• Flare B Aerobic exercise B Analgesics

techniques (walking, biking, swimming) B Relaxation techniques

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Educational Flyer for Plantar Fasciitis

What is plantar fasciitis?

Planta is the Latin word for the “bottom of your foot.” The plantar fascia (or foot fascia) is a tough band of tissue that connects your heel bone to your toes. This band gives your arch support. With prolonged standing, excess activity, or wear and tear with aging, this band can become tight and cause pain. Plantar fasciitis gives you a severe pain on the bottom of your heel that is the worst when you first get up in the morning or after sitting for a long time. The pain usually improves with continued walking.

How is plantar fasciitis treated?

Plantar fasciitis is treated with anti-inflammatory medications (such as Motrin® or Naprosyn®), supportive shoes with good arch support, foot orthotics, and stretch- ing exercises. Helpful orthotics will cushion the heel and prevent the foot from roll- ing over toward the arch. Stretching exercises should be performed frequently throughout the day. Whenever you are lying down or sitting, remember to frequently push your heels down while you pull your toes and foot up. This should cause a gentle pulling sensation in the bottom of your foot. Try to keep your ankle at a 90q angle. Avoid postures where your foot bends away from the front of your leg; for example, do not wear high heels because they hold your foot in this bad position.

When you first get up in the morning and before bed, hold an ice pack to the bottom of your foot for 10 minutes. Then do these stretches:

• Sit with your knees bent and your heels on the floor. Hold the ends of a bath towel in both hands and loop the middle under your toes. Pull the towel up toward your knees, pulling your toes up while your heels stay on the floor. Hold for 10 seconds. Relax and repeat. This stretch may initially be painful, but it should feel better after several stretches.

• Stand facing a wall. Place your painful foot 2 feet away from the wall. Place your other foot about 6 inches away from the wall. Put your hands at shoulder height against the wall and tip forward so your face is near the wall. Feel a stretch behind the calf of your painful foot. Hold 10 seconds. Relax and repeat.

After several repetitions, switch feet and repeat.

• Place several small objects on the floor, such as coins, buttons, or marbles.

Practice picking them up with your toes.

Where can I learn more about plantar fasciitis?

Good information about plantar fasciitis and its treatment can be found at these websites:

• http://familydoctor.org/140.xml

• http://www.aafp.org/afp/20010201/477ph.html

• http://www.intelihealth.com/IH/ihtIH?t=31156&p=~br,IHW|~st,24479|~r, WSIHW000|~b,*|

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Mrs. Inwood was asked to meet with the nurse practitioner and dietician to help get her diabetic management under better control. She also met with a psychologist for stress management and cognitive behavioral therapy to assist with diabetic management and pain control. She was given an educational flyer about peripheral neuropathy (Box 2). Although her neuropathy pain would probably be reduced with either antidepressants or an anti-epileptic, such as gabapentin (Neurontin) or pregabalin (Lyrica), an antidepressant was selected to treat her comorbid depressive symptoms. Because of previous poor toler-

Box 2

Educational Flyer for Peripheral Neuropathy

What is peripheral neuropathy?

Neuron is the medical term for “nerve.” The nerves that go to your arms, legs, hands, and feet are called the peripheral nerves. Pathos is the Greek word for “suf- fering.” Therefore, a peripheral neuropathy is suffering or discomfort of the periph- eral nerves, usually affecting the feet.

Many medical illnesses, including diabetes, thyroid disease, rheumatoid arthritis, and kidney disease, can cause damage to the peripheral nerves. This damage causes the feet to become numb, tingle, burn, or pained.

How is peripheral neuropathy treated?

In many cases, treating your medical condition will make the peripheral neuropa- thy better. For example, if you are a patient with diabetes, getting your blood sugar under control will help your nerves work better and will lessen the pain they are causing.

There are no medicines to improve the nerve function in peripheral neuropathy.

Therefore, no medicine will get rid of your numbness. There are medicines that make the numbness less unpleasant and reduce the burning, tingling, and sensitivity that often occur with peripheral neuropathy. Medications that were originally devel- oped to treat mood disorders (such as Elavil®, Tofranil®, and Cymbalta®) and sei- zures (such as Neurontin®) also reduce the unpleasant sensations of peripheral neuropathy.

Aerobic exercise can also reduce the unpleasant feeling in the feet in patients with peripheral neuropathy. Walking at least 30 minutes every other day also pre- vents the development of peripheral vascular disease, another common cause of pain- ful feet in patients with diabetes and other medical illnesses.

Where can I learn more about peripheral neuropathy?

Good information about peripheral neuropathy and its treatment can be found at these websites:

• http://familydoctor.org/050.xml

• http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheral neuropathy.htm

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Nonmedication Medication

• Restorative B Orthotics B NSAIDs

treatment B Calf muscle-stretching exercises B Steroid injections into B Surgical nerve release flexor retinaculum

• Preventive B Avoid excessive exercise B None therapies B Avoid compressive boots

B Orthotics

B Calf muscle-stretching exercises

• Flare B Ice B Analgesics

techniques B Restricted exercise

NSAIDs, nonsteroidal anti-inflammatory drugs.

ability of tricyclics, she was prescribed the dual-action antidepressant duloxe- tine (Cymbalta®), which is an FDA-approved treatment for diabetic peripheral neuropathy, with good clinical efficacy demonstrated after 2 weeks of treat- ment, including for nighttime pain.

2.4. Tarsal Tunnel Syndrome

Tarsal tunnel syndrome may be effectively managed in many patients with conservative treatment that involves rest, avoidance of ankle compression, ice, and anti-inflammatory drugs (Table 10). Patients failing to achieve relief with these measures may respond to steroid injections into the flexor retinaculum.

In recalcitrant patients, surgical release may be needed. A survey of tarsal tun- nel release on 45 affected feet reported good to excellent relief in 60% (18).

Ms. Johnson was provided with an educational flyer (Box 3) and advised to restrict weight-bearing exercise until symptoms resolved. She was also advised to use ice and ibuprofen (Motrin®). In addition, she was cautioned about over- stressing the ankle with exercise and advised to use regular stretches routinely before exercise once she resumed her regular exercise program. As is typical for backpacking-induced neuropathy, Ms. Johnson’s symptoms resolved with conservative treatment during the course of approximately 3 weeks (10).

2.5. Morton’s Neuroma

Morton’s neuroma may initially be treated conservatively by ensuring the use of nonconstrictive footwear, restricting activities the put pressure on the ball of the foot (such as running, jumping, and dancing), and using cushioned pads under the metatarsals or orthotics to reduce pressure on the neuroma, ice, and anti-inflammatory drugs (Table 11). If these treatments are inadequately effective, local steroid injections may be helpful. Some patients will require surgical resection, which produced long-term improvement in 80% of patients

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Table 11

Targeted Treatment of Morton’s Neuroma

Nonmedication Medication

• Restorative B Wear roomy, comfortable shoes B NSAIDs

treatment B Orthotics and metatarsal pads B Local steroid injections

• Preventive B Avoid high heels and tight or B None therapies pointed-toed shoes

B Orthotics and metatarsal pads

• Flare B Ice B Analgesics

techniques B Metatarsal pads

NSAIDs, nonsteroidal anti-inflammatory drugs.

Box 3

Educational Flyer for Tarsal Tunnel Syndrome

What is tarsal tunnel syndrome?

Tarsos is the Greek word for “ankle.” A nerve runs under a tunnel on the inside of your ankle to get to the bottom of your foot. This tunnel in your ankle is called the tarsal tunnel. With too much exercise or pressure on the inside of your ankle (e.g., from tight skates or hiking boots), this tunnel can get pressed and pinch the nerve that runs through it. When this nerve is pinched, you will develop a burning pain and possibly numbness in your ankle, heel, and over the sole and arch of your foot.

How is tarsal tunnel syndrome treated?

If tarsal tunnel symptoms begin after a period of ankle overuse or compression, they will usually improve with anti-inflammatory drugs (such as Motrin® or Naprosyn®), rest, ice, and wearing foot orthotics. If you are an athlete, wear good- fitting, supportive foot wear and avoid excessive training. Orthotics may also be helpful. Persistent symptoms may require a surgical release of the posterior tibial nerve that runs under the tarsal tunnel.

Where can I learn more about tarsal tunnel syndrome?

Good information about tarsal tunnel syndrome and its treatment can be found at these websites:

• http://www.medterms.com/script/main/art.asp?articlekey=11564

• http://www.footphysicians.com/info2.php?id=10

in one series (19). Repeated injections with alcohol-sclerosing therapy are effective for about 90% of patients with Morton’s neuroma, with long-term relief (20,21). This may provide an effective option for patients who prefer to avoid surgery. In one report, Morton’s neuroma was treated in 115 patients with staged therapy consisting of education, footwear modification to wider shoes, and placement of a metatarsal pad as stage 1, local steroid plus anes-

(17)

thetic injection as stage 2, and surgical excision as stage 3 (22). Patients waited 3 months in each stage before determining efficacy and the need for additional treatment. After completing stage 1 conservative treatment, 41% of patients were satisfied with their improvement. An additional 47% of patients who failed stage 1 treatment and were treated with injections were satisfied with their relief. Only 24 patients (21%) progressed to surgery, with improve- ment in 23 of these postoperatively (96%).

Mrs. Klein was given an educational flyer on Morton’s neuroma (Box 4) and agreed to switch her pointed-toe stilettos for a flat shoe with ample toe room, which she agreed was more comfortable and still attractive. A metatarsal pad was placed in her shoe for added cushioning. She minimized wear-bearing activities and used ice after walking, along with daily naproxen (Naprosyn®).

Educational Flyer for Morton’s Neuroma

What is Morton’s neuroma?

Neuron is the medical term for “nerve.” Oma is the Latin word for “swelling.”

Therefore, a neuroma is a swelling or thickening around a nerve. The thickening of a neuroma is caused by repetitive minor trauma to the nerve or its surrounding struc- tures. In 1876, Dr. Morton described a painful foot condition where a thickening occurs in the nerve going to your toes. This thickening occurs in the ball of your foot. This condition was named Morton’s neuroma. People with Morton’s neuroma often complain that they feel like they are walking on a marble. Pressing or walking on this thickening can cause a severe burning pain in your foot.

How is Morton’s neuroma treated?

In many cases, Morton’s neuroma is thought to occur from wearing tight-fitting shoes, especially high heels with pointed toes, which squeeze the ball of your foot.

The first step to treating Morton’s neuroma is to rest the foot and use ice packs.

Switch to comfortable, low-heeled shoes that have lots of room at the front of the foot. Wearing orthotics or pads to cushion the ball of your foot may also be helpful.

Anti-inflammatory medications (such as Motrin® or Naprosyn®) are also usually helpful. If these simple measures do not help, a cortisone injection may be benefi- cial. In some cases, surgical removal of the neuroma will be needed.

Where can I learn more about Morton’s neuroma?

Good information about Morton’s neuroma and its treatment can be found at these websites:

• http://www.mayoclinic.com/invoke.cfm?objectid=CB793439-A249-45C7- B4B089DBC882B8D8

• http://www.footphysicians.com/info2.php?id=20

• http://www.intelihealth.com/IH/ihtIH?t=24456&p=~br,IHW|~st,24479|~r, WSIHW000|~b,*|

(18)

This provided only limited improvement, and she was treated with a local cor- tisone injection, with good symptomatic relief.

3. SUMMARY

Every foot pain in patients with diabetes is not necessarily caused by periph- eral neuropathy or vascular disease. Although none of these four patients had peripheral arteriopathy as a cause of foot pain, peripheral vascular pain or clau- dication also occurs commonly in patients with diabetes. Using a Doppler ankle/brachial index less than 0.9 for diagnosis, peripheral arterial disease can be identified in about 25% of patients with diabetes (23,24). Patients with vas- cular claudication usually describe coldness of the feet at rest, with diffuse foot aching, cramping, fatigue, and pain with walking. Other risk factors for vascu- lar claudication include smoking, hypercholesterolemia, and hypertension. The treatment of peripheral arterial disease includes risk factor modification, antiplatelet agents, cilostazol (Pletal®) in patients without heart failure, and exercise (such as walking 30 minutes every other day). Focusing on foot pain location, quality, and response to walking helps differentiate among the com- mon causes of chronic foot pain.

REFERENCES

1. Garrow AP, Silman AJ, Macfarlane GJ. The Cheshire Foot Pain and Disability Survey: a population survey assessing prevalence and associations. Pain 2004;110:

378–384.

1a. Marcus DA. Chronic Pain: A Primary Care Guide to Practical Management.

Totowa, NJ: Humana Press, 2005.

2. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors.

Foot Ankle Int 2004;25:303–310.

3. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case–control study. J Bone Joint Surg Am 2003;85A:872–877.

4. Daousi C, MacFarlance IA, Woodward A, et al. Chronic painful peripheral neur- opathy in an urban community: a controlled comparison of people with and with- out diabetes. Diabet Med 2004;21:976–982.

5. Tesfaye S, Chaturvedi N, Eaton SM, et al. Vascular risk factors and diabetic neu- ropathy. N Engl J Med 2005;352:341–350.

6. De Block CE, De Leeuw IH, Van Gaal LF. Impact of overweight on chronic micro- vascular complications in type 1 diabetic patients. Diabetes Care 2005;28:1649–1655.

7. Börü ÜT, Alp R, Sargin H, et al. Prevalence of peripheral neuropathy in Type 2 diabetic patients attending a diabetes center in Turkey. Endocrin J 2004;51:563–567.

8. Mahan KT, Rock JJ, Hillstrom HJ. Tarsal tunnel syndrome. A retrospective study.

J Am Pod Med Assoc 1996;86:81–91.

9. Jackson DL, Haglund BL. Tarsal tunnel syndrome in runners. Sports Med 1992;

13:146–149.

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11. Watson BV, Algahtani H, Broome RJ, Brown JD. An unusual presentation of tarsal tunnel syndrome caused by an inflatable ice hockey skate. Can J Neurol Sci 2002;29:386–389.

12. Yamamoto S, Tominaga Y, Yura S, Tada H. Tarsal tunnel syndrome with double causes (ganglion, tarsal coalition) evoked by ski boots. Case report. J Sports Med Phys Fitness 1995;35:143–145.

13. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int 1999;

20:214–221.

14. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long–

term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;

329:977–986.

15. Huang CC, Chen TW, Weng MC, et al. Effect of glycemic control on electro- physiologic changes of diabetic neuropathy in type 2 diabetic patients. Kaohsiung J Med Sci 2005;21:15–21.

16. Goodnick PJ. Use of antidepressants in the treatment of comorbid diabetes melli- tus and depression as well as in diabetic neuropathy. Ann Clin Psychiatry 2001;13:

31–41.

17. Wiffen P, Collins S, McQuay H, et al. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rev 2005;20:CD00113.

18. Mahan KT, Rock JJ, Hillstrom HJ. Tarsal tunnel syndrome. A retrospective study.

J Am Pod Med Assoc 1996;86:81–91.

19. Ruuskanen MM, Niinimaki T, Jalovaara P. Results of the surgical treatment of Morton’s neuralgia in 58 operated intermetatarsal spaces followed over 6 (2–12) years. Arch Orthop Trauma Surg 1994;113:78–80.

20. Dockery GL. The treatment of intermetatarsal neuromas with 4% alcohol scleros- ing injections. J Foot Ankle Surg 1999;38:403–408.

21. Fanucci E, Masala S, Fabiano S, et al. Treatment of intermetatarsal Morton’s neu- roma with alcohol injection under US guide: 10-month follow-up. Eur Radiol 2004;14:514–518.

22. Bennett GL, Graham CE, Mauldin DM. Morton’s interdigital neuroma: a compre- hensive treatment protocol. Foot Ankle Int 1995;16:760–763.

23. Bundo M, Auba J, Valles R, et al. Peripheral arteriopathy in type 2 diabetes mel- litus. Aten Primaria 1998;22:5–11.

24. Lange S, Diehm C, Darius H, et al. High prevalence of peripheral arterial disease and low treatment rates in elderly primary care patients with diabetes. Exp Clin Endocrinol Diabetes 2004;112:556–573.

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